antenatal evaluation of the fetus using fetal movement ... · antenatal evaluation of the fetus...

Antenatal Evaluationof the FetusUsing FetalMovement MonitoringMARIA D. VELAZQUEZ, MD, andWILLIAM F. RAYBURN, MDDivision of Maternal-Fetal Medicine, Department of Obstetrics andGynecology, University of New Mexico Health Sciences Center,Albuquerque, New Mexico

The concept of monitoring fetal body move-ments has existed for more than a century.Early knowledge of fetal neurologic func-tion was based on maternal perception ofaborted fetuses and on systematic studies ofnewborn infants. Information on how the fe-tus moves and about quantitative and quali-tative movement patterns during gestationhas become available in the last few de-cades. Real-time ultrasound has allowed aquality assessment of the comprehensivemotor repertoire in healthy and undisturbedfetuses in their natural environment. This in-formation has enabled characterization offetal movements in growth-restricted fe-tuses, fetuses destined to deliver prema-turely, and those with either congenital mal-formations or chromosomal disorders.

This manuscript addresses the monitor-

ing of fetal movements, focusing on meth-ods to record and classify different activi-ties. Relations between fetal movement andeither simultaneous fetal heart rate (FHR)accelerations or external stimuli are de-scribed, especially in relation to a cascade offetal testing. Limitations to fetal movementmonitoring and special considerations arediscussed.

Fetal Surveillance TechniquesMethods to monitor fetal movement rangefrom charting maternally perceived move-ments to sophisticated methods requiringspecialized equipment operated by skilledprofessionals, such as real-time ultrasonog-raphy, Doppler ultrasound, and electronicFHR monitoring.

MATERNAL PERCEPTIONPerceived fetal motion by a compliantgravida is the simplest and least expensivetechnique for monitoring fetal well-being in

Correspondence: Maria D. Velazquez, Department ofObstetrics & Gynecology, University of New Mexico,2211 Lomas Blvd. NE (ACC 4), Albuquerque, NM 87131.E-mail: [email protected].

PROD. # GRF20402

CLINICAL OBSTETRICS AND GYNECOLOGYVolume 45, Number 4, 993–1004© 2002, Lippincott Williams & Wilkins, Inc.

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 45 / NUMBER 4 / DECEMBER 2002

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the second half of pregnancy. It requires nomonitoring devices or laboratory proce-dures. Independent studies have reported asignificant positive correlation between ma-ternal perception of fetal movement andmovements confirmed by ultrasound scan-ning from 28 to 43 weeks of gestation.1

Several methods for charting fetal kickcounts are described in Table 1.2–9 Althoughseveral protocols have been used, neither theoptimal number of movements nor the idealduration for counting them has been de-

fined. The definition of decreased fetal ac-tivity is therefore not universal.

An attractive method is the “count to 10”technique.8 This method is simple and canbe performed at any convenient time. Table2 shows an example of a “count to 10” chart.Patients can easily provide a “report card”for the fetus by noting whether the fetus re-ceived an A, B, C, D, or, rarely, F. An F rat-ing should be evaluated with further testing;the woman should contact her healthcareprovider for specific instructions.

TABLE 1. Techniques for Monitoring Perceived Fetal Motion

Study (year)Definition of DecreasedFetal Activity Recording Periods

Pearson and Weaver (1976)2 <10 movements/12 h 12 hours (9:00 AM–9:00 PM) daily

Sadovsky and Polishuk (1977)3 <2 movements/h 30 minutes to 1 hour,twice or three timesdaily

Neldham (1980)4 �3 movements/h One 2-hour period,three times weekly

O’Leary and Andrinopoulos(1981)5

0–5 movements/30 min for each of thethree 30-min periods

Three 30-minuteperiods, daily

Harper et al (1981)6 Complete cessation Three 1-hour periods,daily

Leader et al (1981)7 1 day of no movements or 2 successivedays/week in which there are <10movements/h

30 minutes, fourtimes daily

Rayburn (1982)8 <3 movements/h for 2 consecutivehours

>1 hour (whenconvenient)

Picquadio and Moore (1998)9 <10 movements/h for 2 consecutivehours

Count to 10movements (no timerestrictions)

TABLE 2. Example of a “Count to 10” Fetal Kick Count Chart

Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday

A B C D F A B C D F A B C D F A B C D F A B C D F A B C D F A B C D FA B C D F A B C D F A B C D F A B C D F A B C D F A B C D F A B C D FA B C D F A B C D F A B C D F A B C D F A B C D F A B C D F A B C D FA B C D F A B C D F A B C D F A B C D F A B C D F A B C D F A B C D FA B C D F A B C D F A B C D F A B C D F A B C D F A B C D F A B C D FA B C D F A B C D F A B C D F A B C D F A B C D F A B C D F A B C D FA B C D F A B C D F A B C D F A B C D F A B C D F A B C D F A B C D FA B C D F A B C D F A B C D F A B C D F A B C D F A B C D F A B C D F

To know more about your baby, we ask you to count how many minutes it takes you to feel 10 distinct movements (kick, stretches, orrollovers—not hiccups). Do this anytime while lying on your side. Circle the letter corresponding to the number of minutes.

A = 0–15 minutes; B = 16–30 minutes; C = 31–45 minutes; D = 46–60 minutes; F = >60 minutes.

994 VELAZQUEZ AND RAYBURN

The patient should be encouraged to lieon her side and to concentrate on fetal move-ment. For many women, evening hours aremost convenient for movement charting.Despite a commonly held belief, a recentmeal or juice intake is not necessary, be-cause gross fetal body movements are unaf-fected by maternal glucose levels. Fetal limband body movements, breathing move-ments, heart rate, and Doppler velocitywaveforms are not affected by maternal glu-cose levels as low as 45 mg/dL.10

The patient should be clearly instructedabout the specific technique of recordingperceived fetal movement. The importanceof recognizing decreased fetal activity mustbe stressed. Most women are compliantwhen they understand the rationale for fetalmonitoring and are informed that the proce-dure usually requires no more than 1 or 2hours per day.11 Continued encouragementby a consistent healthcare professionalyields the most complete findings.

Fetal movement charting may enhancematernal–fetal bonding. Having the fatherperiodically help with charting may alsoprove useful in the family attachment pro-cess and in some cases may reinforce com-pliance. The small number of women whoare incapable of recording perceived fetalmovement often improve their perceptiveability when viewing activity during real-time ultrasound examinations.

REAL-TIME ULTRASOUND IMAGINGDirect observation of fetal movement overextended periods is permitted using real-time ultrasound imaging without disturbingthe fetus. Two-dimensional images are pro-duced by placing an ultrasound transducer,usually 3.5 MHz, on the maternal abdomenalong the axis of the fetal thorax and abdo-men. Two transducers used simultaneouslyto visualize the whole fetus have been usedfor research purposes. A 5- to 30-minute ob-servation period is commonly considered tobe adequate. The frequency, intensity, andduration of fetal movements are correlatedwith maternal perception of the movements.

Certain movements of lesser duration or in-tensity, observed during an ultrasound ex-amination, are not usually perceived.

Although ultrasound assessment of grossbody movements is important as a diagnos-tic index of fetal well-being, the underlyingmorphologic substrate of these movementsand their functional significance during pre-natal life are less clearly understood. Thislack of knowledge is related in part to lim-ited information about the ultrastructure ofthe central nervous system and muscles inthe fetus, particularly synapse and motorend plate formation. Shortcomings of ultra-sound investigations of fetal movement pat-terns and their developmental course relateto the relatively short duration of observa-tion (usually only a few minutes) and thelack of repeated observations.

Comparisons of longitudinal observa-tions of fetal behavior with the well-established patterns of postnatal behavior inlow-risk premature infants have revealedstriking similarities between fetal and pre-term infant behaviors at the same concep-tional age. Identical movement patterns inthe fetus may be observed after birth, alongwith certain specific movements such as theMoro reflex that represent an apparent adap-tation to the extrauterine environment. Ter-minology used to describe movement pat-terns in the newborn applies before birth.12

The reduced effect of gravity in utero maycause a more gradual drop of an elevatedlimb. Similarly, flexion of the head or rota-tion of the body, which is normally seen ininfants, is observed in utero because of thebuoyancy effect of amniotic fluid.13

DOPPLER ULTRASOUNDFetal movement may be documented byDoppler ultrasound. Faterni et al14 foundpulsed Doppler and B-modes to be associ-ated with fetal stimulation. When this mo-dality is used, the fetus is observed in a dis-turbed state.14

Limb and trunk movements can be re-corded with very low-frequency signals bypassing the Doppler signal through a band

Fetal Movement Monitoring 995

filter.15 In contrast, unprocessed raw signalsmay impede the analysis of movement.Electronic monitoring systems are com-monly used for the continuous automatic,time-synchronous recordings of gross fetalbody movements and heart rate. TheHewlett-Packard M-1350-A (Boeblingen,Germany) Doppler device is reported to rec-ord 94% of isolated limb movements, 95%of spinal flexion and extension movements,97% of rolling movements, and 100% ofcomplex combined movements observed byultrasound.16 Prolonged fetal movementsare usually recorded as many movements ofshorter duration, whereas brief discretemovements of lower intensity are ineffi-ciently detected.

FHR MONITORINGFetal movement and the onset of FHR accel-erations are synchronized and coordinatedfunctions. DePietro et al17 showed that cou-pling of fetal movement and FHR occurs assympathetic and parasympathetic innerva-tions develop. A heart-rate accelerationlagged 5 seconds behind the body move-ment at 32 weeks. Doppler and real-time ul-trasound studies have shown an associationbetween fetal trunk movement and the FHRpattern. Adequate accelerations (�15 bpmand lasting >15 seconds) are associated with79% of fetal movements perceived by thepregnant women and 99% of fetal move-ments seen sonographically.18 Smaller ac-celerations are correlated with 53% of per-ceived movements and 82% of those re-corded by ultrasound. A nonreactivenonstress test (NST) pattern is associatedwith either few or no Doppler-detected fetalmovements.

Vibration is a potent stimulus to elicit fe-tal movements and heart rate changes. Anelectrolarynx firmly applied against the ma-ternal abdomen, having an output of ap-proximately 110 dB in a frequency range of250 to 850 Hz, can produce a vibroacousticstimulus.19 When the stimulus is applied forat least 3 seconds to a normal fetus duringbehavioral state 1F (when the FHR variabil-

ity, body movements, and eye movementsare the least), an abrupt increase in fetalmovements is observed that may last for anhour. The typical fetal response consists of astartle reaction characterized by a head aver-sion, arm movement, and leg extension. Vi-broacoustic stimulation is used often as atest for fetal well-being during periods oflow FHR reactivity owing presumably to re-duced motor activity. Fetal movement in re-sponse to this stimulation correlates withumbilical blood pH values of 7.20 or greaterin situations in which initial FHR monitor-ing is neither reassuring or nonreassuring.9

van Heteren et al noted, however, that fe-tuses with chromosomal abnormalities orbrain anomalies may not respond to acousticstimulation even in the absence of fetal hyp-oxia.20,21

Evidence that the near-term fetus canhear has been offered for many years. Sev-eral systematic and well-controlled studieshave shown a state of dependence similar tothat in the newborn infant. In a randomizedcontrolled trial using acoustic stimulation,Marden et al22 reported that 89% of fetuseshad increased body movement, and stimula-tion was associated with a reactive NST re-sult in 99% of cases.

The effect of external light stimulation onfetal behavior was examined by Kiuchi etal.23 A positive response to a flashlight wasobserved by FHR acceleration and bodymovement when the fetus was in an awakerather than in a sleep cycle. This responsewas less than with vibroacoustic stimula-tion, which occurred during any behaviorstate.

Characterization of FetalMovementsA distinction between fetal movements canbe based on strength and speed (eg, weak vs.strong, short vs. sustained) of the wholebody or limb-only movements. Table 3 de-scribes different types of observed fetalmovement using this distinction. Althoughthis type of characterization has been used


since Reinold’s pioneering work, the com-plexity of movements exceeds the limiteddiscrimination power of such categories.

A systematic approach has been de-scribed by DeVries et al24 within the con-ceptual context of developmental neurol-ogy. Their investigations were preceded by alongitudinal study by Prechtl and Nolte ofstrictly selected, low-risk preterm infants.12

These infants were chosen “because they arethe only group whose behavior can be com-pared, with any meaning, with the recordedbehavior of the intrauterine fetus during un-disturbed pregnancies.” Repeated observa-tions of fetuses by DeVries were videotapedon a longitudinal basis for 1 hour during thesecond trimester and for 2 hours during thethird trimester.24 The fetal movements werecharacterized as follows:

Startles are quick generalized movements thatalways begin in the limbs and often spread tothe trunk and neck. The duration of a startle is1 second or less. Usually, these movementsoccur singly but sometimes may be repetitive.Startles can be superimposed on a generalbody movement.

General body movements are slower movementsthat involve the whole body. They last from afew seconds to a minute. A peculiarity ofthese movements is the indeterminate se-quence of arm, leg, neck, and trunk move-ments (stretches, rollovers). The movementswax and wane in intensity, force, and speed.Despite this variability, these patterns are dis-tinct and easy to recognize.

Hiccups are phasic contractions of the dia-

phragm, often repetitive at regular intervals.A bout of hiccups may last as long as severalminutes. In contrast to the startle, the move-ment always starts in the trunk but may be fol-lowed by involvement of the limbs.

Fetal breathing movements are usually para-doxical. Every contraction of the diaphragm(which after birth leads to an inspiration)causes an inward movement of the thorax anda simultaneous movement of the abdomenoutward. The sequence of “breaths” is eitherregular or irregular. No amniotic fluid entersinto the collapsed lungs during inspiration.Isolated breaths may resemble a sigh.

Isolated arm or leg movements (weak kick orjab) may occur without other body parts mov-ing. The speed and amplitude of these move-ments vary.

Twitches are quick extensions or flexions of alimb or the neck. They are neither generalizednor repetitive.

Clonic movements are repetitive tremulousmovements of one or more limbs at a rate ofapproximately three per second. More thanthree or four beats are rare in normal fetuses.

The total repertoire of these fetal move-ments involves motor patterns observed af-ter birth. Although the newborn’s behaviormatures rapidly, the striking similarity be-tween fetal movements and postnatal motorpatterns facilitates a consistent and compre-hensive descriptive classification and termi-nology.

If monitoring fetal motion is useful inpredicting fetal compromise, then one mustbe aware of movement patterns as theychange with gestational age. Fetuses studied

TABLE 3. Characterization of Fetal Body Motion During the Second Half of Gestation

MaternalPerception Visualized Movement Types of Motion Duration/Strength

Rollover, stretch Whole fetal body Rolling andstretching

Sustained/strong(3–30 sec)

Kick, jab, startle Trunk and extremity Simple or isolated Short/strong(1–15 sec)

Flutter, weak kick Lower extremity Simple Short/weak(<1 sec)

Hiccup Chest wall andisolated extremity

High frequency Rapid/weak(<1 sec)

From Rayburn.8


longitudinally by DiPietro et al25 from 20weeks’ gestation to term display these bio-physical changes: progressively slowerheart rate, increased beat-to-beat variability,reduced but more vigorous motor behavior,coalescence of heart rate and movement pat-terns into distinct behavioral states, and in-creased cardiac responsivity to stimulationwith advancing gestation. Qualitative andquantitative measures of fetal activity do notdecrease appreciably during the week beforedelivery.1 This observation dispels the com-mon belief that a sudden loss or decrease inmovement is predictive of impending labor.

Role in Fetal SurveillanceThe compromised fetus presumably reducesits activity to decrease oxygen requirements.Documented cessation of activity warns ofimpending death.3,8,9 A gradual reduction inactivity is more often associated withchronic rather than acute fetal compromise.Approximately of inactive fetuses are still-born, tolerate labor poorly, or require resus-citation at birth.8

Fetal movement charting has become auseful adjunctive test for fetal assessment inhigh-risk pregnancies. Although such appli-cations may be beneficial, questions regard-ing patient acceptability, the need for furtherfetal testing, and the perinatal implicationsof unwarranted intervention must be an-swered before the universal application offetal movement charting protocols can berecommended.

If a patient reports fetal inactivity lastingmore than 1 hour, then her perception shouldbe confirmed. Any underlying complicationmust be sought. Fetal surveillance should beassessed more precisely either by electronicFHR monitoring or by ultrasound visualiza-tion (the biophysical profile). Althoughthere is no evidence as to how promptlythese women should be examined, we rec-ommend evaluation within 12 hours of thewoman’s perception of fetal inactivity. Thefindings must be carefully conveyed to the

patient so that she does not experience un-due anxiety.

The patient reporting fetal inactivity ac-cording to the charting technique should bequeried as to whether she rested and concen-trated on counting. If the patient remains un-certain regarding the inactivity, she shouldbe instructed to count for another hour and tonotify the provider again if few movementsare felt. When cessation of movements isperceived, confirmation and further fetalevaluation should be initiated. An NST is anappropriate first step in evaluating these pa-tients. In women with low-risk pregnancies,a reactive FHR pattern is reflective of an ac-tive fetus and is predictive of a favorableoutcome in approximately 93% of cases.26 Ifthe NST result is nonreactive, then either acontraction stress test or a biophysical pro-file is necessary. Unlike Doppler ultrasound,real-time ultrasonography permits an im-proved recognition of specific movementpatterns. Direct visualization with ultraso-nography provides an opportunity to local-ize fetal cardiac motion, search for majormalformations, and semiquantify amnioticfluid volume.

If a vigorous fetus is confirmed, move-ment charting should still be encouraged un-less the patient feels uncomfortable in rely-ing on this screening method. A lack of bodymovement during sonographic observationmay warrant transabdominal vibroacousticstimulation. A vibroacoustic stimulus-evoked fetal startle response, observed dur-ing ultrasonography, is a good predictor of areassuring biophysical profile score (8–10)in almost all cases.27 Subsequent biophysi-cal profile testing or delivery may be indi-cated depending on the clinical situation orif the score is lower.1

Limitations to MovementMonitoringEvery fetal movement monitoring techniqueis fallible. Examples of limitations includeexpense and equipment needs, and failure to


anticipate certain fetal deaths, malforma-tions, or growth abnormalities.

EXPENSE AND PATIENTINCONVENIENCEOptimal assessment of fetal well-being re-quires continuous rather than intermittentmonitoring of movement. Monitoring oftenrequires evaluation for 30-minute periods orlonger with costly equipment (ultrasonogra-phy, electronic FHR monitor, Doppler ultra-sound) operated by skilled professionals.Consequently, monitoring is usually per-formed only weekly or semiweekly. Evalu-ation is to begin when the pregnancy hasreached a critical stage (usually >32 weeks)when extrauterine survival is very probableand delivery is an acceptable option.

The daily perception of fetal activity hasthe distinct advantages of no cost and theability to monitor at any time and place.However, expecting the pregnant woman tomonitor her fetus for more than 1 hour dailyfor long periods can lead to complianceproblems.

PREDICTING FETAL GROWTHPerceived fetal movement patterns are inac-curate for detecting most growth abnormali-ties. Growth-restricted fetuses exhibit sig-nificantly lower activity rates than normallygrown fetuses at all gestational ages whenevaluated consistently by ultrasound,28 eventhough fetal activity may be perceived as be-ing normal by the gravida. Diminished ac-tivity can be anticipated in only the most se-vere cases, such as fetuses in the lower fifthpercentile for estimated weight. When so-nography confirms that a fetus is small forgestational age, an underlying medical, ge-netic, metabolic, or chronic inflammatoryprocess should be considered. Activity pat-terns of fetuses large for gestational age arethought to be indistinguishable from activitypatterns of appropriately sized fetuses. Anexception would be a severely hydropic fe-tus with polyhydramnios in whom activity isperceived to be significantly less.

DETECTING MALFORMATIONS ANDTHEIR OUTCOMESOnly a few malformations or fetal condi-tions affect movement. Excess activity, de-fined clinically as an average of more than40 perceived motions per hour for at least 14days,29 may represent a fetal anomaly suchas anencephaly. Rapid seizure-like move-ment has been described among brain-deadfetuses who are decerebrate with hyperto-nicity.30 A lack of vigorous motion may re-late to abnormalities of central nervous sys-tem pathways or, less commonly, to muscu-lar dysfunction, skeletal abnormalities, ormechanical restriction of the lower extremi-ties. Inactivity has been documented in fe-tuses with major malformations such as hy-drocephalus, bilateral renal agenesis, and bi-lateral hip dislocation.31 A malformationshould be considered when activity is notperceived in the presence of oligohydram-nios or polyhydramnios.

Fetal movement charting has not beenuseful in predicting outcomes in the pres-ence of malformations. Sonographic studiescan improve our understanding about cen-tral nervous system development and theformation of fetal movement patterns.Weekly recordings comparing a normalwith an anencephalic fetus in a twin preg-nancy have provided insight into the devel-opment of the central nervous system.32 Ce-rebral matter above the medulla oblongataplays an important role in the elimination offetal movements, such as startle and writh-ing, and in the commencement of breathingmovements.32 In the fetus with an open neu-ral tube defect, kicks may be perceived asbeing normal by the pregnant woman. Legmovements below these lesions seem to beof normal quality when assessed with real-time ultrasound. Longitudinal follow-up ofthese fetuses reveals that fetal and early neo-natal leg movements are not predictive ofpostnatal motor function. Early sensoryfunction is strongly related to the level ofopen spinal defect, however, and accuratelypredicts final motor outcome in mostcases.33


REDUCING ANTEPARTUMSTILLBIRTHSThe value of fetal movement charting to re-duce antepartum stillbirth has not beenproven. Its application to low-risk pregnan-cies is attractive because approximately halfof stillbirths occur without obvious cause.8,9

The diagnosis of fetal death, especiallywhen unexplained, necessitates prompt de-livery for meticulous gross and microscopicexamination of the stillborn infant, umbili-cal cord, and placenta. Most clinical trials offetal movement monitoring involve too fewcases to predict the risk of stillbirth. In alarge study of more than 68,000 pregnan-cies, Grant et al34 randomized these patients,regardless of risk category, either to rou-tinely perform movement charting or to dono charting. Women in the charting armwere instructed to record the time needed tofeel 10 movements each day. Women in thecontrol group were informally asked aboutmovements during prenatal visits. Antepar-tum death rates for normally formed single-tons were similar in the two study groups,regardless of risk status. Most stillborn fe-tuses were dead by the time the mothers re-ceived medical attention. The investigationconcluded that maternal perceptions werethought to be as good as routinely chartedfetal movements.

No technique of fetal surveillance canpredict all stillbirths. When movement pat-terns are reassuring, the low proportion ofunfavorable outcomes is usually related toacute hypoxic events, presumably from anumbilical cord compression or a placentalabruption.8,34 An autopsy often shows noobvious abnormalities. On careful question-ing, the patient frequently describes a sud-den loss of perceived movement shortly be-fore fetal death is confirmed.

LIMITATIONS OF DOPPLERULTRASOUNDDoppler ultrasound can neither distinguishbetween types of body movements nor de-tect very subtle movements. Single or clus-ter recordings of movements reflect isolated

kicks or more coordinated trunk and extrem-ity movements such as stretches or roll-overs.16 As is true for maternal perception,Doppler ultrasound cannot detect fetal activ-ity such as rapid eye, breathing, and handmovements. In addition to missing certainforms of movement, Doppler ultrasound canrecord unwanted signal artifacts, usuallycaused as the woman moves or when theDoppler beam is repositioned. Experience inrecognizing such artifacts and in reducingsuch extraneous movement helps the clini-cian determine which recordings more accu-rately indicate fetal body movement.

Special Considerations

FETAL SLEEP–WAKE CYCLESAn appreciation of fetal sleep–wake cyclesis important when evaluating fetal move-ment. Being independent of the maternalsleep–awake state, fetal “sleep cyclicity”has been described to vary considerably.Timor-Tritsch et al35 reported that the meanlength of the quiet or inactive state for termfetuses was about 23 minutes. Patrick et al36

measured gross fetal body movements withreal-time ultrasound for 24-hour periods in31 normal pregnancies and found the long-est period of inactivity to be 75 minutes.

In the third trimester, when fetal move-ment monitoring is more clinically appli-cable, behavioral states are established innearly all fetuses. Nijhuis et al37 studied thecombination of FHR patterns, eye move-ments, and whole body movements to de-scribe four distinct fetal behavioral states:

State 1F is a quiescent state (quiet sleep), with anarrow oscillatory bandwidth of the FHR.

State 2F includes frequent whole body move-ments, continuous eye movements, and widerFHR oscillation. This state (active sleep) isanalogous to rapid eye movement (REM) inthe neonate.

State 3F includes continuous eye movements inthe absence of body movements and no FHRaccelerations.


State 4F is one of vigorous body movementswith continuous eye movements and FHR ac-celerations. This state corresponds to theawake state in infants.

Fetuses spend most of their time in the twosleeping states, 1F and 2F. The state 3F hasbeen disputed.38

MATERNAL EXERCISEOne ultrasonographic study of the effects ofmaternal exercise (20 minutes of aerobicdance) on fetal behavior in late gestationshowed a significant decrease in fetalbreathing but no significant change in shoul-der movement or kick response.39 Effects oflow-impact exercise on the fetus are mildand transitory, and fetal movement chartingimmediately after this activity is not neces-sary.

Heavy maternal exercise affects the fetuswith signs of transient impairment. In 12healthy women, Manders et al40 reportedthat the number of fetal body movements in-versely correlated with the percentage ofmaximal increase in maternal heart rate. TheFHR and breathing movements decreasedsignificantly when the maximal increase inmaternal pulse exceeded 90%. At this levelof cardiac stress, two cases of fetal bradycar-dia were reported, followed by reduced FHRvariability and the absence of body andbreathing movements for 20 minutes.

SUBJECTIVELY LESS FETALMOVEMENTA bothersome clinical situation occurs whenwomen present in late gestation with a con-cern about feeling less fetal movement. Har-rington et al41 reported that 7% of pregnantwomen at a London hospital presented forthis reason. FHR monitoring was under-taken if ultrasound scans for fetal growth orDoppler velocimetry were abnormal. Preg-nancy outcomes for these women were notsignificantly different than a control groupof women without this complaint. This con-dition among women who did no chartingmay have been reduced if instructions tochart had been given.

EFFECTS OF MEDICATIONS

Sedating drugs such as alcohol, barbitu-rates, narcotics, methadone, or benzo-diazepines are known to cross the pla-centa easily. Significantly more NST resultsare nonreactive or take longer to become re-active in the methadone-maintainedgravida. Biophysical profile scores are re-ported to be the same before and aftermethadone dosing in 75% of women.42 Ko-pecky et al43 noted that morphine adminis-tered to the mother may significantly de-crease the biophysical profile score by re-ducing fetal breathing (80%) and by an NSTbeing nonreactive (60%). Neither move-ment nor tone was affected. Altered behav-ior is expected to reverse after clearance ofthe drug.

Possible effects of maternal antiepilepticmedication on fetal movement have beenexamined between 32 and 38 weeks’ gesta-tion.44 No marked differences in patterns offetal motion and FHR were observed, and noobvious effect on fetal neuromuscular de-velopment could be found.

Changes in fetal activity have beenobserved in patients receiving the cortico-steroids betamethasone and dexametha-sone. Mulder et al45 reported that on thesecond day after betamethasone admini-stration, FHR variability was reduced by20% and body and breathing movementswere reduced by 49% and 85%, respec-tively. All values returned to normal by thefourth day after dosing, indicating a tran-sient effect from the corticosteroid. Mushkatet al46 found that betamethasone led to de-creased fetal movement as perceived bythe mother and as observed by ultrasound.It was also associated with decreasedfetal breathing. Administration of dexa-methasone did not influence fetal wholebody movement, although breathing was di-minished after 24 hours postdosing.46 Nei-ther drug affected the basal heart rate, beat-to-beat variability, or number of accelera-tions.


DISTINGUISHING BETWEENMULTIPLE FETUSESOnly direct visualization with ultrasonogra-phy can distinguish between multifetal preg-nancies. Videotaped recordings of twinpregnancies by Arabin et al47 showed thatcontacts between fetuses that producemovement by the other twin may begin by11 weeks’ gestation, or even earlier if twin-ning is monochorionic rather than dichori-onic. Ultrasound imaging often shows “box-ing matches” that last a few minutes and thatare separated by rest periods. This type ofactivity may explain why the whole bodymovements of twins are thought to be morefrequent than those of singletons.48 The pa-tient’s perception that both fetuses are activeis reassuring; however, the patient fre-quently reports that one fetus is more activethan the other. The mother’s ability to dis-tinguish between fetuses from day to day isunreliable with most multifetal gestations.

SummaryMonitoring fetal movement serves as an in-direct measure of central nervous system in-tegrity and function. The gradual coordina-tion of whole body movement in the fetus,which requires complex neurologic control,is similar to the coordination of movementin the preterm newborn infant. Monitoringhas its greatest value when placental insuf-ficiency is long-standing; its routine role inlow-risk pregnancies requires further clini-cal investigation. The presence of a vigorousfetus is reassuring. Perceived inactivity is ascreening method that requires a reassess-ment of any underlying antepartum compli-cation and a more precise evaluation byFHR testing or real-time ultrasonography.Evidence is lacking that monitoring fetalmovement is an effective independent sur-veillance technique for predicting fetalgrowth, malformation, and stillbirth.

Acknowledgments:Certain portions of material presented herewere also published in Obstetrics and Gyne-

cology Clinics of North America, Volume26, December 1999. Permission was ob-tained from the publisher.

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